Assessing the governance environment for private sector engagement in health in Africa: Results from a multi-country survey

Background The role of the private sector in health is clear in many countries but engagement can be improved. The World Health Organization (WHO) developed a global strategy in 2020 focused on engaging the private sector in health service delivery through governance in mixed health systems and detailed six governance behaviours to guide its Member States. To operationalise these global ideas into practice, the Regional Office for Africa conducted a multi-country study to understand perceptions around the six governance behaviours. This article examines the perceptions of respondents from 13 African countries on the governance environment for private sector engagement in health. Methods Data were collected through an online survey that was distributed to individuals from ministries of health and their partner organisations, private sector institutions and initiatives in countries and development organisations (n = 81) across 13 countries. The survey was based on the following six governance behaviours: build understanding, enable stakeholders, nurture trust, foster relations, align structures and deliver strategy. Results Results showed that respondents had mixed perceptions of the governance environment for private sector engagement in health in their respective countries. Although 88% of respondents (n = 63/72) were familiar with the general inclusion of the private sector in national health sector plans, 63% of respondents (n = 45/71) noted there was limited or no integration of the private sector in the health system, and further, 28% of respondents noted there was no private sector reporting in health information systems (n = 19/69). Key opportunities presented in more than one governance behaviour include: (i) increasing private sector engagement in public sector activities, (ii) establishing clear roles and responsibilities through formal partnership agreements, (iii) improving data sharing through shared health information systems, (iv) incentives and subsidies, (v) capacity building, (vi) creating norms, guidelines, and regulations and (vii) conducting joint monitoring and evaluation. Many of these outlined overlapping concepts are not exclusive to one behaviour, thus, it is evident that when targeted, there is the potential to improve numerous governance behaviours. This further reiterates the view that the governance behaviours should be understood as connected and not unrelated areas. Conclusions The study provides insight into the perceptions of respondents from select African countries on the governance environment for private sector engagement in health. These findings can inform the development of strategies and interventions to support and enhance private sector engagement in health in the region.

 Integrate the private sector in public sector activities (e.g., joint monitoring committee; engagement in procurement; common planning, budgeting, and implementation; establish a unified health system; create an umbrella organization for private sector actors to enhance communication; capacity building of both private and public sector personnel)  Develop norms, guidelines, and/or partnership agreements for PSE and each sector, such as a memorandum of understanding that outlines roles and obligations (e.g., can draw inspiration from other structures where alignment exists, establish regulations, develop pricing guidelines, create an annual supervision schedule and execute) o Ensure that these are disseminated to the private sector and that the public sector has the capacity to and will monitor and enforce private sector fulfilment of these guidelines o A first step can be to form a PSE technical working group and create a framework  Conduct a survey to identify private sector participation in the health sector2

Build understanding
What do you think can be done to foster relations and build dialogue between public and private sector stakeholders?
 Facilitate formalized dialogue between ministries of health and private sector actors, including civil society (e.g., host weekly meetings, establish a forum for networking, have a dedicated secretariat) o Decentralize dialogue to countries  Improve coordination and accountability (e.g., establish an exchange and/or coordination platform, joint planning, shared health information system platforms, create private-public network, transparency in the management of health care funds)  Encourage participation in existing structures (e.g., private engagement in national health policies and strategies, private sector data in health reviews)  Establish partnership agreements that have win-win-win solutions (e.g., formalize an inclusive and sustainable PSE or bipartite consultation framework)  Develop a policy framework for PSE  Use COVID-19 as an argument to reiterate that all sectors need to be engaged to better control epidemics and improve health (i.e., multisectorality)  Reduce fragmentation between government entities that engage with the private sector and vice versa  Consider that there should not be a sole representative for either the public or private sector, instead consider engaging with a multitude of corporatist organizations  Explore the Global Fund's existing Country Coordination Mechanism to assess if other entities can join Foster relations What do you think can be done to enable stakeholders using regulation and financing towards national health goals?
 Improve the application of relevant government texts or create them where absent (e.g., health financing strategies that emphasize the notion of "invested with a public mission")  Build regulatory capacity for institutions (e.g., audit training) or strengthen the functions of regulatory bodies using health laws  Consider incentives for the private sector through financing mechanisms (e.g., loan opportunities to invest in health) and for regulatory bodies to enforce rules (also consider subsidies for both sectors)  Develop clear regulations and a comprehensive regulatory framework and ensure compliance with standards  Harmonize pricing at the private level and adopt strategic purchasing to ensure fair access to public and private providers  Undertake classification of health services and products  Improve the social insurance network  Improve transparency (e.g., compulsory private sector disclosure for engaging in social insurance, re-establish government authority after criticism)  Engage stakeholders with sustained communication efforts  Promote a culture of excellence in the recruitment of health professionals and reinforce their capacities   (2012-2025)   Yes "An effort to improve organization, accountability and the search for results will be required in order to create the foundations for sustainable health development.The PNDS foresees the strengthening of the sector's institutional framework, the search for forms of financing adapted to new needs, the dynamization of the policy for training cadres, the establishment of a fruitful relationship with the private health sector, and the active participation of local administrations, communities, and families in the process of improving health" (p.4).
"The detailed budget of the programs will be presented in a second phase, following the discussion and validation at the national level of the proposed operational strategies and activities, through a broad X 3 The most recent plan that was available online was assessed. 4Reports in French and Portuguese were translated into English using DeepL software. 5This question was posed to respondents under "deliver strategy".We provide it here along with our assessment of each country's plan inclusion of the private sector that was agreed upon by M.A. and J.N.-O.

Yes
"The national health system includes the public, private and traditional medicine and pharmacopoeia sub-sectors…Full communalization will have a major impact on the way the health system is managed at all levels.The private health care sub-sector has 358 facilities, most of which are for-profit (81.56%) and religious establishments located mainly in the cities of Ouagadougou and Bobo Dioulasso.Laws regulating the private practice of health care professions have been adopted" (p. 6).
"The private health sub-sector, which is developing without a master plan, is not sufficiently integrated into the health system and there are still gaps in the application of legal texts and in compliance with service delivery standards…However, there is (i) little development of sectoral dialogue between the government and its technical and financial partners, with insufficient functioning of the monitoring committee and technical commissions, (ii) no real coordination of projects and programs and their management units, and (iii) weak coordination at the level of the private sub-sector" (p, 7).
"In addition, the private health care sub-sector plays an important role in the provision of health care, particularly in urban areas.However, at the national has not provided itself with the necessary means to establish agreements capable of improving the use of available resources in order to achieve the desired complementarity between the public and private sectors.The lack of articulation between the two sectors with regard to a greater exchange of information is notorious, particularly in the sending of statistical data and in the notification of cases of diseases that must be reported.Given the increased expectations of Cape Verdeans and the dynamics of tourism, it is necessary that the private health sector develop and assert itself more and more as the desired complement to the public sector" (pp.12-13).
"The partnership should also develop in a publicprivate framework, which is also useful for the health sector" (p.49). "

2021-2025
Yes "Through this new National Development Plan, which will mobilize approximately 59,000 billion CFA francs over the period 2021-2025, expected mainly from the private sector, we intend to accelerate the population's access to education, drinking water, electricity, health care, social protection, employment, etc.We will also pursue the development of the private sector, giving it a new lease on life, to make it the real engine of our economy.This will include the local processing of our raw materials, the strengthening of infrastructure and the promotion of national champions, in order to create more jobs, especially for young people and women" (p.3).
"Private sector and investment development to improve the overall competitiveness of the economy.These include strategies and programs to promote the private sector and investment, develop finance and infrastructure, strengthen the business climate, and expand domestic, regional and international markets to increase trade and investment" (p.15).
"The Plan also aims to transform the culture and practices within the administration and private institutions, to foster values and attitudes that are conducive to development.The aim is to raise the level of national and social awareness through a true cultural transformation, anchored in the educational system as well as in public administration and in private workplaces and places of worship, associations and non-governmental institutions" (p.16).
X (2017-2020) Yes "The challenge is also on the private side by regularizing the roles of pharmacies and pharmaceutical warehouses and guaranteeing the quality of imported products through single national markets, managed by CAMEC and involving importers, which will also have the advantage of increasing market levels and reducing intermediaries who tend to increase costs.The implementation of these actions within a framework of promoting the X 7 Only Volume 2 was assessed, as Volume 1 was unavailable for download.
rational use of medicines and an integrated system (at least at the regional level) of management, supply, distribution and storage is also a real challenge for the coming years" (p.9).
"Strengthened leadership and health governance through effective and efficient management of resources, effectively focused on results at all levels, and by strengthening the financing and participation of health system actors, particularly communities and the private sector" (p.12).
"The SNIS will continue to receive special attention, enabling it to continue and strengthen its scaling-up efforts in order to effectively cover all public and private health structures.In this context, the initiatives undertaken (e.g.DIHS2) will be strengthened and put to good use for more effective monitoring of the health system and the implementation of the PNDS" (pp.13-14).
"The monitoring of maternal and neonatal deaths has been made compulsory in all public and private health structures, and harmonized tools will be put in place to facilitate the annual publication of a national report on the audit of these deaths, which will be the subject of wide-ranging national meetings involving the governmental sectors, active nongovernmental organizations, the private health sector and the TFPs" (p.17).

Nigeria
Second National Strategic Health Development Plan

2018-2022
Yes "Nigeria runs a pluralistic health care system with public and private sectors, modern and traditional systems providing health care" (p. 6).
"Nigeria has a growing private health sector which provides 60% of the health care services through 30% X of the country's conventional health facilitiesthis includes not-for-profit services provided by faithbased and non-governmental organizations; and private-for-profit providers.The broader private health sector also includes traditional medicine providers, patent and proprietary medicine vendors (PPMVs), drug shops and complementary and alternative health practitioners" (p. 7).
"Routine health facility data collection is done through the DHIS 2 platform, which harvests data from 38,500 private and public primary and secondary facilities.While DHIS 2 average reporting rate in 2017 was 72%, timeliness remained low at 63%.Completeness is also a huge challenge with reported service data being significantly lower than national estimates from other known sources.There is very little to no reporting from the private sector despite the fact that the private sector provides 60% of healthcare services in the country" (p.36).
"The private investment in health research and development is also very poor.Finally there is a disconnection between research in academic institutions in the country and the consumers of research findings.This calls for a pragmatic national research agenda that can inform public health policy and practice" (p.37).
"Opportunities to broaden the revenue base for public health care financing including, sin taxes, aviation, VAT, health insurance, public-private partnerships e.g.corporate social responsibility, health impact bond and philanthropy have not been fully harnessed" (p.38). "

Yes
"There is a considerable gap in knowledge and data on the private sector for healthcare in Sierra Leone.The private sector appears to be an important provider of services, especially a) in terms of health service provision at the secondary and tertiary level, with many hospitals known to be in operation across the country, and b) a considerable network of private sector pharmacies and informal drug peddlers.However, the sector is not formally organized around a series of trade associations, and data on utilization and sales either does not exist or is not easily accessible.Regardless of these gaps, the private sector will be considered as part of the overall approach to improving healthcare in Sierra Leone.Several new initiatives are already considering the role of private sector pharmacies, for example, including an effort to organize a network of providers who can provide drugs to Ebola survivors" (p.30).
"Strategic Objective 9: Understand, engage and organize the private sector for healthcare: 9.1.Commission a private sector landscape analysis: The first step will be to understand the scope of private sector activities on healthcare in Sierra Leone.This will produce a clear overview and database of private sector hospitals, clinics, laboratory service providers and registered pharmacies, as well as some estimation of unregistered pharmacies and drug peddlers.Some comparison of public vs private sector utilization, service quality and cost will also be included as part of the exercise.9.2.Develop a strategy to engage and organize the sector: Based on the landscape, the MoHS and its partners will come together for a series of discussions X with key private sector stakeholders to discuss how the private sector can be better engaged in order to deliver improved health outcomes to the people of Sierra Leone.This may include the establishment of key bodies and associationssuch as an association of private sector hospitalsthat would help the public and private sectors engage in a more organized fashion.This should yield a private sector engagement plan that can be an addendum to the HSSP" (p.30).
"The ministry of health shall;… ii) Develop a publicprivate partnership for health policy to harness the complementary benefits of the private health sector.
iii) Strengthen partnerships with the private sector to include delegation, contracting, and collaboration among other forms of partnerships" (p.27). X

Table S2 .
Select mentions of the private sector in national health policies or health sector plans

Select mentions of the role(s) of the private sector 4 "Does the national health policy (also known as a strategy in some countries) include the private health sector?" 5
X level, private health establishments account for only 13% of the population's health care needs, and the private sector's participation in public health activities is low….The number of Ministry of Health staff in the public sub-sector was estimated at 19,899 in May 2010.Private health care institutions employ nearly 1,800 people, 8% of whom are doctors (143), 37% nurses (669), 12% midwives and midwives (216), and the rest low-skilled personnel.8The private health care sub-sector contributes to training with the medical school of the University of Geneva.The private health sub-sector contributes to the training offer with the Faculty of Medicine of the University of St. private sector, philanthropic or forprofit, and its regulation, as a privileged partner in the task of making health care available" (p.27)."The private sector is an important element of the SNS and tends to assume its complementary role in the provision of health care.With legal support since 1989 [18], it developed, essentially in Praia and Mindelo, through the creation of medical and dental offices, clinical analysis laboratories, physiotherapy offices, and private pharmacies.Almost all professionals in the private health sector are in a regime of accumulation of work with public services.The State has not yet created the conditions to encourage the development of this sector or to exercise its regulatory and oversight role.Likewise, it ThomasAquinas and the private school Ste Edwige (training of paramedics) in Ouagadougou" (p.9)."The supply, distribution, availability and accessibility of health products have improved significantly in recent years.Drugs are imported by the Centrale d'achat de 10ormalizati essentiels génériques et des consommables médicaux (CAMEG) and nine (9) private wholesalers (Cophadis, Laborex, Pharmaplus, Faso Galien, Multi M, DPBF, ISDA, COPHARMED, Pharma International).As for distribution, in 2010, it is ensured by 144 private pharmaceutical dispensaries, 800 depots of essential generic drugs in public structures and 500 private drug depots" (p.10)."Theimplementation of the PNDS 2011-2020 will be done through three-year plans, hospital establishment projects, regional development plans and district health development plans.The latter will take into account communal development plans and the plans of all the other actors in the health area (private structures, NGOs/ associations, etc.)" (p.37)."…Inaddition, in the absence of a national regulatory policy, some public sector physicians continue to work in the private sector.To address the shortage of doctors in rural hospitals, and in particular surgeons, a strategy for district hospital surgery has been developed" (p.28)."Thenumber of paramedical schools increased from 4 in 2005 to 25 in 2013 (17 private, 2 denominational and 6 public).Over the same period, the number of medical schools producing general practitioners has increased from one to more than three53 without the same growth in teaching and supervisory staff or teaching materials.Compliance with standards by private training institutions is regularly a problem and raises questions about the quality of the staff they produce" (p.28).
Private health sector in sustained expansion, with domestic and foreign investment, playing a better role as a complement to the public sector and offering a greater variety of services" (p.20).
In 2005, the FMOH developed the PPP Policy to provide a framework for the involvement of the private sector in the development of infrastructure and To increase the number and proportion of new patients with TB (all forms) diagnosed and notified -(referred) by non-public service providers-(CHWs referral) and private health facilities from 24.1% in 2014 to 40 % by 2020" (p.39)."Health Workforce Education: At present, 25 public and private training institutions across Sierra Leone offer 56 different education programs, ranging from certificate to Master's level" (p.49)."Strategic Objective 4: Establish and promote partnerships among public, private and not-for-profit stakeholders: Under this strategic objective, MoHS aims to establish the cooperation and partnership from all sectors necessary to achieve the goal of this HRH Strategy.Across the government and regulatory agencies, inter-ministerial coordination is necessary to plan for, develop, and finance the national workforce.Within MoHS, effective, community-based participation is necessary to improve health worker accountability and management.Partnerships with private-sector, non-governmental, and faith-based organizations in service delivery, education, and technology is paramount to resourcing and implementing the HRH Strategy successfully" (p.50).Institute measures for rational use of medicines and guide procurement and donations of medicines in public and private health facilities…."(p.20)."The Ministry of Health shall; i) Advocate for increased private and public funding of the health budget.ii) Ensure harmonization and alignment of development assistance for health funding with national policies, strategies and priorities iii) Explore options for pre-payment schemes to hasten achievement of universal coverage where insurance options such as; private insurance, social insurance, insurance specialised care, community health insurance etc. shall be considered.iv) Introduce User Fees in private wings of public hospitals" (p.21)."Explore mechanisms for capturing private sector data through the Private Public Partnership for Health desk and health data from health facilities of partners,